GENERAL MEDICAL RECORD STANDARDS for SPECIALISTS

(applicable to paper or electronic medical records)

Appropriate health education is documented on all patients

Care is rendered in a timely and appropriate manner

All pages contain patient identification

There is biographical/personal data

There is only one patient's medical record in a chart

All progress notes are signed or initiated by writer

Every entry is dated

The record is legible to someone other than the writer

Errors are appropriately marked through and initialed

Allergies and adverse reactions or the notation NKA is clearly documented

Past medical history is documented

Past history relating to condition is documented

Physical findings are recorded at every encounter

Diagnosis is recorded at every encounter

Presenting problem or symptoms are documented

Documentation of smoking, if relevant to condition

Documentation of alcohol use, if relevant to condition

Documentation of illicit drug use, if relevant to condition

Instructions regarding dose, frequency and length to take are documented when medication is prescribed

Medication given in the office is identified by name, site route given & dose

The plan of treatment is documented

Follow up plan is documented

Problems from previous visits are addressed

There is evidence of continuity and coordination of care between specialist and primary care physician

If diagnostic tests are ordered, the results are documented

The attending has noted the results of the diagnostic tests

The attending has documented what was done regarding abnormal results

The patient received notification of abnormal test results

If the patient was seen at more than one office there is a procedure to ensure the medical record is available whenever and whereever the patient is seen